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lD �-'3 <br /> SAN JOAQUIN COUNTY 9LIC HEALTH SERVICES - ENVIRONMENTAL HEALTH •BION <br /> UNDER%W40 STORAGE TANK P - FEE WORKSHEET <br /> S FACILITY SITE NAME TACT NAME <br /> T ^� r x tm Bearctt�E FACILITY ADDRESS with AREA CODE <br /> $ 1-p� 82 4 1CITY TANKSA Crr� FITE <br /> P <br /> P APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> BeN1,10 Ta i c Gr <br /> C MAILING ADDRESS APPLICANT PHONE # WITH AREA CODE <br /> N 14 67 L, APDrf11,-372- 1g S <br /> T CITY STATE STATE ZIP CODE TYPE of APPLICATION <br /> Q 1 p C,1� Q� (Closure, Installation, etc.) /KS]Aa..4jj'.4 <br /> TOTAL <br /> 1986 1987 1988 1989 1990 <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) = 5100.00 ) <br /> A f N A <br /> C <br /> T FACILITY PENALTY FEES ASSESSED (If Applicable) XXXX XXX)( S N Q <br /> I <br /> V TANK FEE = 550.00/TANK (Prior to January 1,1991) 5170/TANK (After January 1, 1991) <br /> E <br /> # Tanks 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 <br /> F (multiply # by fee for <br /> C each year applicable) S 0 <br /> 1 TANK PENALTY FEES ASSESSED XXXX XXXX S ^/ <br /> L <br /> 1 STATE SURCHARGE = 556.00 each TANK (Due every 5 years) See California H 8 S Cade, Section 25287 <br /> T <br /> Y # Tanks x $56.00 1966 through 1990 1991 through 1996 <br /> (Enter amount and year) c / <br /> V $ b <br /> C PERMANENT CLOSURE (Removal or Authorized Closure-in-Place) TANK I.D. #(s) <br /> L <br /> 0 CLOSURE FEE = 278.00/hour (3 hours minimm/TANK) # TANK(s) X $234.00 f <br /> S <br /> U TEMPORARY CLOSURE (Plan Review 8 Inspections) TANK I.D. #(s) <br /> R <br /> E TEMPORARY CLOSURE FEE = 578.00/hour (3 haus minimun/FACILITY) _ $234.00 minimum <br /> P INSTALLATION PLAN CHECK (Plan Review 8 Construction Inspections) TANK I.D. #(s) <br /> L <br /> A <br /> N PLAN CHECK FEE = 578.00/hour (8 hours minimum/FACILITY) = 5624.00 minimm S 6 Z <br /> R PEPAIR FEE (Workplan Review 8 Construction Inspections) TANK I.D. #(s) <br /> E <br /> P TANK LINING REPAIR FEE _ $78.00/hour (3 hours minimum/TANK) # TANK(s) _ X $234.00 = S ,V1 4 <br /> A <br /> I TANK RETROFIT REPAIR FEE = 578.00/hour (3 hours min./FACILITY) = 5234.00 minimum S <br /> R <br /> PIPING REPAIR FEE = 578.00/hour (3 hours minimxA/FACILITY) = 5234.00 minimm $ <br /> M TRANSFER FEE = 520.00 UNAUTHORIZED RELEASE EVALUATION = f78,00/hr f �f <br /> I <br /> S <br /> C CONSULTATION FEE = 578.00/hr SAMPLING INSPECTION FEE _ $78.00/hr <br /> TOTAL DUE S <br /> FOR OFFICE USE ONLY <br /> .......... <br /> a p G f <br /> ar .saw...w,...m:m..,r..i.srr.wa.a,.ma.....was.rr...m.a.:..a.a.a..am...s.ia..,....a..,.....,.mra.a.aa.a...a...a,..a..a� <br /> EH 23 032 (REVISED 3-1-931 <br />